NAME OF STUDENT: First Middle Last. AGE OF STUDENT: DATE OF BIRTH: Month/Day/Year TELEPHONE: ( )

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1 100 Westminster Drive Rainbow City, AL (256) KINDERGARTEN STUDENT APPLICATION (3K - 5K) For Office Use Only: Date Received: Time Received: Date of Interview: Date Approved: Time of Interview: Business Office: NAME OF STUDENT: First Middle Last PARENT(S): NAME STUDENT GOES BY: BIRTHPLACE: City/State/Country AGE OF STUDENT: DATE OF BIRTH: Month/Day/Year MALE / FEMALE (Circle One) ADDRESS OF STUDENT: Street Address/P.O. Box/Apartment Number City/State/Zip Code TELEPHONE: ( ) SCHOOL YEAR APPLYING FOR: GRADE APPLYING FOR: 3K 4K 5K Preferred Days 2 day (circle one) 3 day 3 day 5 day 5 day 5 day Please list all siblings of the applicant, as well as the additional information requested. NAME AGE GRADE SCHOOL PRESENTLY ATTENDING How did you hear about Westbrook Christian School? Friend Mail Billboard Yellow Pages Family Newspaper Internet Television Other 1 5/19/2010

2 PARENT INFORMATION FATHER Title: Dr. Mr. Rev. (circle one) Last First Child lives with above person: full time part time does not reside with this parent/guardian Relation to child: Parent Step-Parent Grandparent Uncle Legal Guardian (circle one) Address City State Zip ( ) ( ) Home Phone Work Phone County ( ) Cell Phone Employer Occupation MOTHER Title: Dr. Mrs. Ms. Rev. (circle one) Last First Child lives with above person: full time part time does not reside with this parent/guardian Relation to child: Parent Step-Parent Grandparent Aunt Legal Guardian (circle one) Address City State Zip ( ) ( ) Home Phone Work Phone County ( ) Cell Phone Employer Occupation MARITAL STATUS OF PARENT(S): Together Separated Divorced Widowed Single (Circle One) If parents are separated or divorced, who has custody of the child? A copy of the most recently issued Court Order providing custody status must be attached. 2 5/19/2010

3 PREVIOUS SCHOOLING List all schools previously attended: Name of School City/State Grade(s) Attended MAILING ADDRESS OF MOST RECENT SCHOOL: Street Address/P.O. Box City/State/Zip Code Telephone Number of School: ( ) Has this child ever been retained/repeated a grade? If yes, which grade? Explanation: Has this child ever been suspended/expelled from a school? Please describe the nature of any previous disciplinary problems: Has this child been enrolled in a special program of any kind in school? If yes, what type of program (i.e. gifted, learning disabled, occupational therapy, speech, etc.)? The student application process will include an element of assessment in order to provide the most appropriate academic plan for each student. This plan would be based on the results of the evaluation, the academic needs identified and the resources available through WCS. Prior academic educational plans would be used for supplemental information, but would not be the framework for the final plan. MEDICAL Does this child have any physical or emotional problem? If yes what? Has your child ever had a traumatic experience? If yes, please explain. 3 5/19/2010

4 Has your child ever been professionally diagnosed with any of the following: Attention Deficit Disorder Attention Deficit Hyperactive Disorder Sensory Integration Disorder Autism Dyslexia Bipolar Asperger's Syndrome Central Auditory Processing Disorder Other Is medication required for any of the above? If yes, please list. Is the child allergic to any medications? If yes, please list. CHILD'S PHYSICIAN: PHYSICIAN'S TELEPHONE NUMBER: INTERESTS Favorite toys or games: Special interests: Favorite foods: Favorite TV programs: Fun things you do together: RELIGIOUS AFFILIATION Do you consider your home a Christian home? What church do you attend? 4 5/19/2010

5 Are you a member of this church? Which most accurately describes your church attendance? Active in the church Attend occasionally Attend a few times a year Children attend Sunday School Explain briefly why you want a Christian education for your child(ren): FAMILY If you have other children of school age that will not be enrolling in Westbrook Christian School, please explain the reason(s): This information is true to the best of my ability. FATHER'S (OR GUARDIAN'S) SIGNATURE: Date: MOTHER'S (OR GUARDIAN'S) SIGNATURE: Date: Westbrook Christian School does not discriminate on the basis of race, color, gender, or national and ethnic origin in its admission, educational or athletic policies. The school does not provide enrollment to students whose special educational, physical, or emotional needs cannot be met by our existing programs, services, or staff. 5 5/19/2010

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